Psychiatric Annals

EDITORIAL 

Redressing "Descartes' Error"

Jan Fawcett, MD

Abstract

This month's issue of Psychiatric Annals, guest edited by Paul J. Goodnick, MD, is entitled "Medical Illness and Depression. "It is important and worthwhile that we review the areas of "overlap" and comorbidity of medical and psychiatric illness. Although it is of pragmatic importance for the practitioner to keep up to date and sharp in this area, there is much more involved. As physicians and psychiatrists, we still need to address the mind-brain-body split that has been built into our tWnking by Western culture, and by our medical education. It involves the mind-brain split evidenced in the separateness of the language of psychodynamics and neuropsychopharmacology in psychiatry as much as the traditional mind-body split engrained in medicine. As Arthur Frank, PhD, points out in articulating his successful struggle with the fear, pain, isolation, stigma, and uncertainty involved in living beyond cancer in his magnificent book "At the WiU of the Body," physicians can often treat diseases, but do not do well at addressing the human being's illness. He quickly learned that if he wanted to survive, that was "his problem."

Some exciting aspects arising from clinical research indicating the interaction of human feelings with the outcome of medical diseases are reviewed in this month's issue. This is especially notable in the papers on "Depression and Heart Disease" and on "Cancer and Depression," but evident throughout the entire series of contributions in this month's issue.

After a public discussion dealing with the subject of how to get the public and primary care physicians more involved in making the diagnosis of depression, and possibly even initiating treatment, I was confronted by a young man who had suffered from depression and experienced recovery during the course of his analysis. He disagreed with my opinion that the way to be more successful at this was to emphasize the medical aspects of depression as evidenced by showing dramatic PET scans of the hypometabolism of deoxyribose in a depressed patient's brain as compared with normal brain metabolism (Ketter et al, Psychiatric Annals, December 1994). His argument was that this was not the way he and others experienced depression. A biological explanation did not match the experience of depression; he felt others would experience it as dehumanizing. I had to stop and think about this. Was I a victim of Descartes' error or was he (and society) the victim? Why should finding a neurobiological cause of an illness experienced as a psychologic al state be dehumanizing - unless recognizing biological factors has come to stand for total disregard of the human experience of depression? Have we come to the point in our reaction to science that a scientific explanation (which might help derive effective treatment) is viewed prima facie as dehumanizing? I could not dismiss his point. It may indicate how far the mind- brain- body split has developed.

Antonio Damascio, MD, PhD, has addressed this question masterfully in reviewing the history of our understanding of consciousness, neurocognition, feelings, and rational process, and our present state of knowledge of this, in his book "Descartes' Error." The error, of course, was the assumption that thinking and awareness occurred as the result of a mind quite separate from the body. In his postscriptum, Dr. Damascio discusses some of the consequences of this mind-body split for Western medicine. The concentration on physiology and pathology of the body, to the exclusion of human dimensions of illness leading to a medicine that "amputates the concept of humanity with which medicine does its job." The awareness of the effect of people's feelings about their illness on its outcome as well as the role…

This month's issue of Psychiatric Annals, guest edited by Paul J. Goodnick, MD, is entitled "Medical Illness and Depression. "It is important and worthwhile that we review the areas of "overlap" and comorbidity of medical and psychiatric illness. Although it is of pragmatic importance for the practitioner to keep up to date and sharp in this area, there is much more involved. As physicians and psychiatrists, we still need to address the mind-brain-body split that has been built into our tWnking by Western culture, and by our medical education. It involves the mind-brain split evidenced in the separateness of the language of psychodynamics and neuropsychopharmacology in psychiatry as much as the traditional mind-body split engrained in medicine. As Arthur Frank, PhD, points out in articulating his successful struggle with the fear, pain, isolation, stigma, and uncertainty involved in living beyond cancer in his magnificent book "At the WiU of the Body," physicians can often treat diseases, but do not do well at addressing the human being's illness. He quickly learned that if he wanted to survive, that was "his problem."

Some exciting aspects arising from clinical research indicating the interaction of human feelings with the outcome of medical diseases are reviewed in this month's issue. This is especially notable in the papers on "Depression and Heart Disease" and on "Cancer and Depression," but evident throughout the entire series of contributions in this month's issue.

After a public discussion dealing with the subject of how to get the public and primary care physicians more involved in making the diagnosis of depression, and possibly even initiating treatment, I was confronted by a young man who had suffered from depression and experienced recovery during the course of his analysis. He disagreed with my opinion that the way to be more successful at this was to emphasize the medical aspects of depression as evidenced by showing dramatic PET scans of the hypometabolism of deoxyribose in a depressed patient's brain as compared with normal brain metabolism (Ketter et al, Psychiatric Annals, December 1994). His argument was that this was not the way he and others experienced depression. A biological explanation did not match the experience of depression; he felt others would experience it as dehumanizing. I had to stop and think about this. Was I a victim of Descartes' error or was he (and society) the victim? Why should finding a neurobiological cause of an illness experienced as a psychologic al state be dehumanizing - unless recognizing biological factors has come to stand for total disregard of the human experience of depression? Have we come to the point in our reaction to science that a scientific explanation (which might help derive effective treatment) is viewed prima facie as dehumanizing? I could not dismiss his point. It may indicate how far the mind- brain- body split has developed.

Antonio Damascio, MD, PhD, has addressed this question masterfully in reviewing the history of our understanding of consciousness, neurocognition, feelings, and rational process, and our present state of knowledge of this, in his book "Descartes' Error." The error, of course, was the assumption that thinking and awareness occurred as the result of a mind quite separate from the body. In his postscriptum, Dr. Damascio discusses some of the consequences of this mind-body split for Western medicine. The concentration on physiology and pathology of the body, to the exclusion of human dimensions of illness leading to a medicine that "amputates the concept of humanity with which medicine does its job." The awareness of the effect of people's feelings about their illness on its outcome as well as the role of human feelings in the etiology of medical illness has, as a result, been slow in developing. Historical retardation in our understanding of the mind in biological terms and a compartmentalization of diseases resulting in overspecialization, further driven by economics, has created further gaps. He hints that the public's turning toward alternative medicine and "natural treatments" (I might add from my reported conversation above, a distrust and feeling of dehumanization associated with science) may be a result of this split in medicine. Dr. Damascio has much to tell us about the function of our mindbrain-body - well worth reading.

The more we can learn about mind-brainbody interactions, the more effective physicians we can be. We must develop language and concepts that bridge the Cartesian gap. If any specialty in medicine bears that responsibility, it surely is psychiatry.

10.3928/0048-5713-19970501-05

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